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Re: cervical spine HNP
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Re: cervical spine HNP - September 9, 2004 9:36:00 AM
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Dr.Wagner
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I would be extremely conservative with this patient, but ultimately this may be a sugical case. My personal thoughts are to attain strict single approach therapy (ie McKenzie) for a month. Sticking with a single idea and or theory for treatment, creating a plan of action and exhausting efforts to define what actually works (this will also help in the future for acute exacerbations).
I would avoid oral steroids on this patient and certainly not in combination with NSAIDs like ibuprofen.
If she is going to be need anti-inflamatories for >10 days, then a Cox II would be your choice.
Ultimately a surgical consultation may be necessary, and likely should be anticipated.
The diagnostic test of choice is the MRI as Flexion extension views are essentially frowned upon and really only lead to an MRI any way.
THis really is a rough situation for the patient to be in, but I really feel that sticking a particular approach for a length of time may be best (whether that is pure chiropractic vs myofascial vs McKenzie vs whatever). just my thoughts
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Re: cervical spine HNP - September 9, 2004 1:36:00 PM
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FLAOrthoPT
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Mr.Pfister:
Don't worry Obie Wan, I still know the force is strong in you, even though you are stuck behind that desk and root for the Packers..and I would not go against the master...I was only saying: not an "oh no do not do that", but sounds like that typical mva patient whose body convinces them that their problem is way worse than it is, and more behavioral than biomechanical. Too many people babying them from the accident, maybe her medical background could have even hurt her rehab potential. That being so, I was just afraid that if you get someone like this on mech. traction even at 8-10 pounds they may totally guard up and go into spasm and exacerbate symptoms just from the fear of "going on the rack." I highly doubt it is anything unusual, I would bet a lot of money it is nothing surgical even if it is HNP, just flared up area around the nerve root causing guarding and now patterning of behavior with poor motor coordination. I have seen this way too many times to be worried about it base don the case description. However, would still be a bit cautioius about manip or anything agressive, even aggressive stretching just in case there really is some serious sprain causing instability. But a STM, MFR, Activie assisted movement, mulliganish, approach seems to be the best manual approach tied together with some sub-max isometric strengthening in all planes and in combined planes. I still think a steroid pack in the beginning would have done wonders but who cares now. This is the same person who behaviorally develops some nice "s.i.c.k." scapula syndrom from this from all of her shoulder elevation and guarding. But no way is there anything here that says surgical consult, I would ONLY even begin to think that with severe motor weakness as shown in dyn. grip testing, sig. change in muscle tone, muscle atrophy, temperature change in arm, etc. But surgical consult for pain at mid range of motion??? No wonder ortho surgeons have such nice cars...
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Re: cervical spine HNP - September 9, 2004 8:29:00 PM
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Dr.Wagner
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You don't consult a surgeon when there are deficits, you consult before there are deficits.
The primary thought with what I said is there needs to be an organized approach, systematic approach...not a hodge podge.
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Re: cervical spine HNP - September 10, 2004 3:02:00 AM
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SJBird55
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She's only 6 weeks post injury - pain and problems are still to be expected. Just because she has multi-level disc pathology does not necessarily mean that those discs are the sources for her complaints.
Dr. Wag, flexion/extension views are definitely not frowned upon. Our surgeons use them all the time. Many times the referring physician doesn't order them, but orders an MRI. The surgeons want the flexion/extension views because those views are necessary for them to determine what will be performed surgically. The surgeons use their handy dandy ruler and measure in millimeters an anterior or posterior displacement of vertebrae - which then determines if they'll use hardware to stabilize the joint.
From an orthopaedic view, there are still a lot of options for her - and surgery is highly unlikely at this point unless there is some substantial instability. Meds as Dr. Wag mentioned, injections, epidurals, rhizotomy.. if her neuro complaints increased an EMG.... since she has multi-level disc pathology, later down the road a discography might be considered (to help determine what level to focus the above treatments or surgical options).
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Re: cervical spine HNP - September 10, 2004 4:01:00 AM
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Jon Newman
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Hi eam,
You stated, "In order to relieve the pain with extension the pt. rounds her shoulders and gets immediate relief. My view on that one is that just limits her overall extension anyway and that is why she feels better. Not sure, though."
How did the patient know how to reduce her pain? Who taught her that?
jon
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Re: cervical spine HNP - September 10, 2004 4:21:00 AM
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FLAOrthoPT
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do you really think a surgeon would be happy to have someone in their office for whom they are not going to do anything for? Maybe in the hospital it works that way, but if I sent someone over the the ortho and they presented with those symptoms, the ortho would barely even do an eval, not like they do one really anyway, but they would tell the patient go back to therapy and come back in 4 weeks if the pain is still there, then run unecessary MRI, NVC, etc to see if they have justifiable cause to do surgery. But I just do not think they would be too happy to have a PT refer this pt at this point, nor do I think it says too much about the PT if they DO refer out at this point. This is about as typical as they come for cerv s/p MVA. If you send this patient back to the MD that soon, then they'll stop sending them at all, give them some meds for 4 weeks, then justify surgery because "conservative care" did not work. Now the patient has a laminectomy with who knows how much scar tissue and who knows how much altered biomechanics...I am sorry but once again we will agree to disagree on this one, and I hope not too many PTs would refer this one out at this point because it really demeans our profession if we think we are merely a "modality" to be used for 4 weeks to determine if surgery is necessary. I think we should be more of the consult not more of the excuse for surgery. Just my opinion...
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Re: cervical spine HNP - September 10, 2004 4:26:00 AM
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FLAOrthoPT
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I have found that a lot of patients have this, where they shrug and can perhaps extend a bit further, I think one theory for this is when they move their c-spine into extension from the top down, as it was designed to do, they run into either a facet pathology or some sort of extension lesion coupled with instability. the weight of the head moving down the kinetic chain causes increased guarding and therefore dec. ROM. However, if you shrug up, and stabilize from down below you almost reverse the kinetic process and send the c spine into extension from the bottom up creating new mechanics with inferior moving with respect to superior and new stability patterns. Similar to having someone back bend standing and it causes pain, yet if they sit and go into lumbar extension not as much pain. Similar process happening if you picture it, almost reversing the typical kinetic and osteo mechanincs of extension...new patterns may even just trick the body behavioral pain pattern and accomplish extension without pain. I would guess it is good to do for some time to promote the proprio feeling of extension and show the body it can be accomplished without pain. Granted too much of this and you can create some associated behavioral patterns, but I think getting this extra stability from the bottom up and bringing the spine safely and pain free into new ranges should be encouraged...ok All, I am evacuating FLA this time, so probably cannot respond for about a week, so please do me right and defend us from the naysayer...
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Re: cervical spine HNP - September 10, 2004 5:52:00 AM
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Yogi
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EAM, just a sugggestion, this is pretty typical whiplash sounds like, time frame and all. Anyway, everyone so far knows more manual therapy than I, but have you identified the direction of the impact. I used to be able to usually tell that from the eval. If she was hit obliquely or laterally, a vertebral rotation is likely. The bulges don't bother me at present, the radiculopathy can be from the rotation, and the MRI doesn't help identify that. Tenderness laterally of the spinous process on one side, and the opposite side a level above or below, used to warrant a referral to our D.O. for muscle energy. If you or a colleague is familar with MET, it may be the ticket, if not strain/counterstrain is effective also, and you certainly can't mobilize the wrong direction with that.
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Re: cervical spine HNP - September 10, 2004 5:54:00 AM
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chiroortho
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FLOrthoPT, about your post above: [QUOTE]i was guessing because she had lig. damage seen in flexion and ext x-rays...[/QUOTE]For the life of me, I can't find anywhere on this thread that indicates F/E films were obtained. Could you point me to the particular post? I've probably looked right at it 20 times but just can't find it.
Remember that we haven't established that this patient even has real 'disc pathology'. We have only got a comment about 5-level 'protrusions', which may be a completely meaningless finding. Not enough info. Wish you could post the T2-weighted sagittal image here that best delineates the 'protrusions', with corresponding axial cuts.
I have no problem with a surgical consult, but I'm inclined to think that the typical spine surgeon would just send them back. After 6 weeks with this type of pain, though, I don't think it's unreasonable to get a surgical consult if for no other reason than to let the patient know her options (read: put her mind to rest).
I do agree strongly with the 'monotherapy' approach. Too many hands stirring the pot not only tend to work against each other, but can serve to confuse the patient.
One option to consider: nuc med could delineate an occult fracture, eg pillar fx, very well. That would probably be my approach before sending her to the surgeon. Pillar fractures are frequently missed on plain films, but show up nicely on nuc med/SPECT.
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Re: cervical spine HNP - September 10, 2004 5:58:00 AM
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Yogi
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Good luck Fla. I know that's from everyone of us.
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Re: cervical spine HNP - September 10, 2004 6:15:00 AM
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FLAOrthoPT
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the question above that post is why is she wearing it? I said "i was guessing because..."
hope that clears up
going to airport-
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Re: cervical spine HNP - September 10, 2004 6:36:00 AM
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chiroortho
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Thanks for the clarification.
I'm in Melbourne, went to Tampa for Frances and was forced to evacuate our hotel there!
We have power at home, but my office power is still out, estimated fix date: Sept. 18! Unbelievable.
Stay safe.
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Greg Priest, DC, DABCO
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Re: cervical spine HNP - September 10, 2004 6:46:00 AM
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spfister
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HI,
I like the way that this discussion is moving. I agree that this is probably a pretty "normal" whiplash injury. I think that we often don't appreciate the significant soft tissue damage that occurs. Would we be mobilizing a ankle or knee sprain at this point? These things take time to heal and we need to guide the patient through this process to aid healing and minimize compensatory and abnormal movement patterns.
2 notes about responses to my previous post. 1. When I said worry, I really meant a little concerned, things that I would watch, definitely do seem to warrant overreaction at this point.
2. The idea of guarding with traction is why I stated that it would have to be carefully monitored. I think that mechanical cervical traction can be an extremely effect treatment choice that is vastly underused.
Thanks
Steve
PS I'm looking to ride out Ivan at home on the East Coast of Florida, I feel for you on the West Coast of Florida if it follows the track as of today. Good Luck!!!!!
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Re: cervical spine HNP - September 10, 2004 6:48:00 AM
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spfister
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"1. When I said worry, I really meant a little concerned, things that I would watch, definitely do seem to warrant overreaction at this point."
I meant doesn't seem to warrant overreaction,
Sorry.
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Steve
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Re: cervical spine HNP - September 10, 2004 8:18:00 AM
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coloradojulie
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Headaches of cervical origin are typically generated by structures innervated by the first 3 or 4 cervical nerve roots. Identify these structures, and it may be a great place to start.
A concern with whiplash is the natural history of gradual loss of cervical lordosis with the consequence of progressive and accelerated DJD. Prevention of this loss (if possible) is important.
Consider the natural history of any soft tissue ligamentous injury that we treat. Generally speaking you are looking at 6-8 weeks (in the absence of tissue healing disruption) for significant soft tissue healing to mature...however it can take as long as one year for maturity. Consider also that the majority of the soft tissue injuries that we treat do not occur at great velocities, nor do they occur at a site in the body where the lever arm disadvantage is as great in the neck (with the 8-12 pound head at the end).
Rapid acceleration and simultaneous decceleration occurs creating muscle fiber tearing. Consider the mechanism of injury for an achilles tendon tear...rapid stretch followed by a reflexive dynamic contraction...lengthening and shortening muscle fibres tear themselves apart...especially eccentrically.
Ligamentous strain and impingment from ROM extremes and joint dammage due to speed of impact and momentary delay of muscle support (that instantaneous lack of muscle readiness) leading to momentary adverse joint stress.
All of these things point to significant trauma to the soft tissue and joint structures. We know in something like the ankle (which occurs at lower velocities and lacks the "whip" action) can be painful and linger for more than 6 weeks...a grade three for example? Why wouldn't we expect the same or more from the neck when more than just three ligaments are most certainly disrupted.
Often with cervical disc injury patients will find relief by elevating the shoulder girdle, or putting their arm up over their head. Is this reducing nerve root tension? Is it shortening the structures innervated by C1-C4? You could use this position to work on passive cervical extension perhaps with the goal to preserve normal cervical lordosis?
I think to encourage the soft tissue to heal correctly you need to move the tissue within the normal ranges of motion as the patient tolerance allows. Certainly with ligamentous strain, there will be some residual laxity (as we know with any joint that has sustained ligamentous strain, we can expect a certain amount of long term laxity), therefore muscular stabilization is key. Flexibility gained without stability can become problematic.
Perhaps consider using perterbation work (proprioceptive or closed chain challenge) to increase the level of readiness of the supportive musculature to reduce adverse shearing in these lax areas. Very gentle isometrics on a partially deflated ball or cuff (unstable surface)?
I think in many ways we can treat the neck as we would any other joint in the body with soft tissue trauma...of course assuming all bony or neural abnormalities have been ruled out.
Functionally the neck seems to follow the low back, and many of the muscles can be likewise considered synonomous with muscles of the pelvis and low back.
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Re: cervical spine HNP - September 10, 2004 1:42:00 PM
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Dr.Wagner
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I guess I am a Naysayer? I don't have any stakes in this, I am not even a surgeon. I simply stated, "you consult a surgeon before there are deficits, not after" the idea is to PREVENT morbidity, not treat it. Primarily treatment in a conservative approach would be "monotherapy" (ie McKenzie) until a resonable timeframe has passed. This allows the AVOIDANCE of future failures with the same approach or the successful treatment during future exacerbations.
Regarding the surgical opinion, you must exercise your options and not base opinions purely from what they "may" think, or if you believe they "may" send the patient back to you. If there is a patient with questionable findings on the MRI, then refer to someone who can better interpret the findings. Regardless if these were benign disc findings, a 30 year old female with abnormal findings on MRI and happens to be symptomatic is potentially bad news. Pride should not prevent referral. THis likely is NOTHING, but allowing a surgeon the shoulder the risk is to your advantage and shows that you "considered" the option of further morbidity if treatment was delayed. This sharing of liability is important and certainly not a weakness.
As for Flexion Extension views, a primary reason they are avoided is that rarely do they show anything of use that an MRI does not. The worry is the making an ustable fracture into a true problem. The use of flexion extension view is actually pretty controversial and should NEVER be used in the acute patient (trauma phase). Often times it can uncover fractures NOT seen on standard radiographs, but ONLY in the chronic patient. It has been used in older practices, but the prevailing thought is that is has been overused (causing too much radiation for little gain).
Generally the sequence in acute injuries (the concensus view...trauma surgeons, EM doctors and radiologists) is plain 3 view radiographs, then CT of neck, then MRI and only in the subacute phase and only if the spine is considered "stable" then pursue flexion extension views. Oftentimes, the CT is skipped as an outpatient.
That probably clarifies my statement...don't want you to think they are useless, just rarely of much help.
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Dr. Wagner DO
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Re: cervical spine HNP - September 10, 2004 1:48:00 PM
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nari
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Just a quick mention -shrugging of the shoulders is very useful for increasing cervical ROM and decreasing pain. It releases static tension on the nerve roots. But it should be done slowly, and released very slowly, after neck movements are finished.
Elevating shoulders can also assist in thoracic spine movements, though the reason behind that is not really clear to me.
Nari
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Re: cervical spine HNP - September 10, 2004 5:50:00 PM
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eam
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Hi everybody-
Thanks for all the replies. I am actually on a cervical-thoracic manual course this weekend-how timely!
To answer a few questions and comment-
Some of the posters mentioned mm guarding secondary to injury. Her injury was 7/23 and when I evaluated her which was probably a couple of weeks ago-the only noticeable guarding or "hypertonicity" was in the upper/middle thoracic spine-with consequential segmental hypomobililty, not in her cervical mm. Which to me, frankly, was a little worrisome, actually, b/c I expected to see it, I guess.
She is not on any meds right now.
The ER films after the MVA were plain neutral position x/rays-normal according to her. She requested the MRI of her physician b/c she was getting worse. The MRI's did read protrusions and I saw the films-I am by no means an expert (but I do feel we should be able to read MRI's better than we do), but the discs looked pretty nasty to me, obviously some worse than others.
She actually had a surgical consult schedulued before she came in to see me. That will be in a couple of weeks, I think.
My initial reaction to this was to be conservative with her. She is of small stature also, like 5 feet tall and SMALL. Something inside me said "take it easy". Maybe it was the swallowing issue, HA I don't know.
Jon-I do not know who taught her to round her shoulders to relieve her pain, maybe she saw it on one of her clinicals.
She tells me that the sub-max IM's seem to help her but when you still can't take a shower and wash your hair, nothing seems to help.
On my course this weekend, I was talking to one of the instructors and he mentioned that since she is 6-8 weeks post, maybe she is ready for some OA/AA/mid cerv tx/MET. I know these techniques but have been reluctant to do them b/c of some lingering issue in my head re: laxity/instability. Any other thoughts on this? Or on possible rib issues causing her lack of cervical extension?
I will see her on Tuesday and re-test ligs and further question her re:x-ray findings.
Rolf-s/p MVA work related- means that since her job is in pharmaceutical sales and she drives her car for her job,she got into the accident while working. Hence, the disability/workman's comp. issue.
Once again, thanks everyone for the posts-it really challenges the clincial reasoning process!
Erica
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Re: cervical spine HNP - September 10, 2004 6:00:00 PM
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Jon Newman
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Eam,
You stated: "Jon-I do not know who taught her to round her shoulders to relieve her pain, maybe she saw it on one of her clinicals."
I doubt it. Ask her at the next visit.
jon
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Re: cervical spine HNP - September 15, 2004 4:40:00 AM
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eam
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Hi everybody!
To update-I saw my pt. yesterday-she went to the doctor (physiatrist) at the end of last week-
According to the pt, the MD was not that surprised that her progress was slow. She actually recommended to the patient that she wear her collar a little more during the day! Not sure if that was the best suggestion.
Subjectively, she states that she does feel a little better, HA SLOWLY improving. When I saw her sitting in the waiting room-it appeared as if she could not move her neck at all she seemed so stiff. When I got her into the tx room- I re-tested and tested a few more things-strength on her right side has improved, rotation/sb still full and painfree, alar/transverse ligs -negative, elevated-possibly subluxed 1st rib on the left (her sx on the right), OA-tight left anterior capsule. I positioned her in OA extension, side tilted her to the left and her sx's re-appeared and her movt very restricted. I did an MET and she markedly improved and had no pain with significant increase in ROM. She currently is taking Celebrex BID and Flexeral at night. Jon-the shrugging of the shoulders move she performs to decrease her pain-she told me that it just came natural to her to do that. There is so much going on with this girl that I am trying to prioritize and develop a consistent methodology regarding tx-which at times is hard b/c you want to "fix" everything at once. I will keep everyone updated on her b/c she is an interesting case. Any other suggestions please feel free to post. Thank you,
Erica
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